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An SMS Text Message-Based Type 2 Diabetes Prevention Program for Hispanic Adolescents With Obesity: Qualitative Co-Design Process
Abstract
Background:
SMS text message-based interventions are a promising approach for reaching and engaging high-risk youths, such as Hispanic adolescents with obesity, in health promotion and disease prevention opportunities. This is particularly relevant, given that SMS text messaging is widely accessible and available and that adolescents are frequent texters. Including youths in the development of SMS text message content can lead to more acceptable and relevant messaging; however, few studies include this group as cocollaborators.
Objective:
This study aimed to use a co-design process to inform the development of SMS text messages that promote healthy physical activity (PA) and sleep behaviors among Hispanic adolescents with obesity.
Methods:
The co-design framework uses multiple methods across several phases. Self-determination theory and a literature review of SMS text message-based interventions guided the background and research phases. In the co-design phase, Hispanic adolescents (n=20) completed in-depth interviews to identify barriers and facilitators of PA and sleep, preferences for ways to emphasize key self-determination theory constructs (autonomy, competence, and relatedness), and suggestions for making SMS text message content engaging. In the design and content phase, interview findings were used to develop initial SMS text messages, which were then evaluated in the early evaluation phase by experts (n=6) and adolescents (n=6). Feedback from these panels was integrated into the SMS text message content during refinement.
Results:
The background phase revealed that few SMS text message-based interventions have included Hispanic adolescents. Common barriers and facilitators of activity and sleep as well as preferences for ways in which SMS text messages could provide autonomy, competence, and relatedness support were identified in the co-design phase. The youths also wanted feedback about goal attainment. Suggestions to make SMS text messages more engaging included using emojis, GIFs, and media. This information informed an initial bank of SMS text messages (N=116). Expert review indicated that all (116/116, 100%) SMS text messages were age and culturally appropriate; however, some (21/116, 18.1%) did not adequately address youth-identified barriers and facilitators of PA and sleep, whereas others (30/116, 25.9%) were not theoretically adherent. Adolescents reported that SMS text messages were easy to understand (116/116, 100%), provided the support needed for behavior change (103/116, 88.8%), and used mostly acceptable language (84/116, 72.4%). Feedback was used to refine and develop the final bank of 125 unique text messages.
Conclusions:
Using a co-design process, a theoretically grounded, appealing, and relevant bank of SMS text messages promoting healthy PA and sleep behaviors to adolescents was developed. The SMS text messages will be further evaluated in a pilot study to assess feasibility, acceptability, and preliminary efficacy. The co-design process used in this study provides a framework for future studies aimed at developing SMS text message-based strategies among high-risk adolescents.
International registered report identifier (irrid):
RR2-10.1016/j.cct.2023.107117.
... This bidirectional transfer of knowledge guides the research from design to implementation and, ultimately, through broad dissemination [9][10][11][12]. Using qualitative and quantitative co-design methods, we developed Fit24, a 12-week goal setting Fitbit and SMS text messaging intervention in collaboration with a community sample of Hispanic adolescents with obesity [13]. Youth (n=20) completed in-depth interviews to identify barriers and facilitators of PA and sleep, desired behavior change techniques, preferences for support in line with self-determination theory (SDT), and desired goal-setting assistance and feedback. ...
... The intervention protocol has been previously published [13]. Participating youth were randomized (1:1 randomization) to the intervention or to a waitlist control group. ...
... Using the PRISM as a guide, the Fit24 intervention was deemed to be both feasible and acceptable based on participant feedback. These findings are important, as few studies have developed DHIs for Hispanic youth, and even fewer have engaged youth in the development and evaluation of DHIs [9,13]. As the integration of technology into health promotion and disease prevention strategies continues to increase, it is important to identify feasible and acceptable intervention strategies for engaging youth, especially high-risk youth like Hispanic adolescents with obesity who are disproportionately impacted by diabetes [19]. ...
Background
Digital health interventions are promising for reaching and engaging high-risk youth in disease prevention opportunities; however, few digital prevention interventions have been developed for Hispanic youth, limiting our knowledge of these strategies among this population.
Objective
This study qualitatively assessed the feasibility and acceptability of Fit24, a 12-week goal-setting intervention that uses a Fitbit watch (Fitbit Inc) and theoretically grounded SMS text messages to promote physical activity and sleep among Hispanic adolescents (aged between 14 and 16 years) with obesity.
Methods
After completing the intervention, a subsample of youth (N=15) participated in an in-depth interview. We categorized the themes into dimensions based on participant perspectives using the Practical, Robust Implementation, and Sustainability Model (PRISM) framework.
Results
Participants shared positive perceptions of wearing the Fitbit and receiving SMS text messages. Youth were highly engaged in monitoring their behaviors and perceived increased activity and sleep. Almost all youth organically received social support from a peer or family member and suggested the use of a group chat or team challenge for integrating peers into future interventions. However, most youth also expressed the need to take personal responsibility for the change in their behavior. Barriers that impacted the feasibility of the study included the skin-irritating material on the Fitbit watch band and environmental barriers (eg, lack of resources and school schedules), that limited participation in activity suggestions. Additionally, sync issues with the Fitbit limited the transmission of data, leading to inaccurate feedback.
Conclusions
Fit24 is a promising approach for engaging Hispanic youth in a diabetes prevention program. Strategies are needed to address technical issues with the Fitbit and environmental issues such as message timing. While integrating peer social support may be desired by some, peer support strategies should be mindful of youth’s desire to foster personal motivation for behavior change. Findings from this study will inform future diabetes prevention trials of Fit24 and other digital health interventions for high-risk pediatric populations.
In the U.S., Hispanic/Latino populations face increased disparities in both the prevalence and management of type 2 diabetes mellitus (T2DM). This article critically examines the multifaceted nature of T2DM disparities among Hispanic/Latino populations in the U.S. and identifies key factors contributing to T2DM prevalence within these communities, including socioeconomic status, cultural influences, and healthcare access. Utilizing a modified expert consensus procedure, we evaluate the ways in which the National Clinical Care Commission (NCCC) recommendations apply to the Hispanic/Latino community as well as propose recommendations for improved efficacy. Through a comprehensive analysis of government-community health initiatives, food security, environmental exposures, and housing inequalities, we emphasize the need for targeted interventions and health policies to effectively address and dismantle these disparities. Overall, while the National Clinical Care Commission’s recommendations provide a valuable framework for the implementation of policies pertaining to diabetes management and prevention in the general population, our analysis suggests that recommendations may be strengthened by considering the unique cultural, social, and economic needs of the Hispanic/Latino population moving forward.
Background
There is increasing interest in digital technologies to help improve children and young people’s mental health, and the evidence for the effectiveness for these approaches is rising. However, there is concern regarding levels of user engagement, uptake and adherence. Key guidance regarding digital health interventions stress the importance of early user input in the development, evaluation and implementation of technologies to help ensure they are engaging, feasible, acceptable and potentially effective. Co‐design is a process of active involvement of stakeholders, requiring a change from the traditional approaches to intervention development. However, there is a lack of literature to inform the co‐design of digital technologies to help child and adolescent mental health.
Methods
We reviewed the literature and practice in the co‐design of digital mental health technologies with children and young people. We searched Medline, PsycInfo and Web of Science databases, guidelines, reviews and reference lists, contacted key authors for relevant studies, and extracted key themes on aspects of co‐design relevant to practice. We supplemented this with case studies and methods reported by researchers working in the field.
Results
We identified 25 original articles and 30 digital mental health technologies that were designed/developed with children and young people. The themes identified were as follows: principles of co‐design (including potential stakeholders and stages of involvement), methods of involving and engaging the range of users, co‐designing the prototype and the challenges of co‐design.
Conclusions
Co‐design involves all relevant stakeholders throughout the life and research cycle of the programme. This review helps to inform practitioners and researchers interested in the development of digital health technologies for children and young people. Future work in this field will need to consider the changing face of technology, methods of engaging with the diversity in the user group, and the evaluation of the co‐design process and its impact on the technology.
The contribution of this research lies in its dual approach to the question of physical activity (PA) among adolescents, combining objective measurement of PA by teenagers and a comparison of psychological satisfaction through physical activities involving differing degrees of autonomy (i.e., organized or unstructured). Using the conceptual framework of Self-Determination Theory, the analysis also examines the relationship between levels of PA among adolescents and physical self-concept and satisfaction of basic psychological needs during exercise. The study surveyed 129 first-year higher secondary education students from schools in the city of A Coruña. Satisfaction of basic psychological needs during organized and unstructured physical activities was measured using the Basic Psychological Needs in Exercise Scale. PA levels were assessed based on step count per day for a week as measured by an accelerometer. The results show that the daily step average recorded by students (7,400) is below the minimum recommended levels of PA for this age group, that students are more active on weekdays than at the weekend, and that there is no significant difference in PA levels between male and female subjects (T = 0.23, p < 0.05, d = 0.04). Findings from the comparative analysis of the three basic psychological needs show greater satisfaction of the need for autonomy during unstructured activities (T = 6.15, p < 0.001, d = 0.68), and greater satisfaction of the need for competence during organized activities (T = −2.50, p < 0.05, d = 0.27). No variation in terms of sex was found in relation to satisfaction of the need for autonomy or relatedness from unstructured activities; however, girls showed notably lower satisfaction than boys in relation to the need for competence (T = −2.62, p < 0.01, d = 0.49). Self-esteem was found to play an important mediating role and observed to be strongly related to sex (T = −5.16, p < 0.001, d = 0.90). Organized PA was found to provide greater need satisfaction among boys than girls across all categories. The study showed no relationship between psychological variables and objectively measured PA (Pillai’s trace: F = 0.86, p > 0.05, η² = 0.08, observed power = 0.66). Basic psychological needs show significant positive interrelation between them and a significant positive relationship between them and physical self-concept, as expected based on previous literature.
While evidence suggests that interventions based on self-determination theory have efficacy in motivating adoption and maintenance of health-related behaviors, and in promoting adaptive psychological outcomes, the motivational techniques that comprise the content of these interventions have not been comprehensively identified or described. The aim of the present study was to develop a classification system of the techniques that comprise self-determination theory interventions, with satisfaction of psychological needs as an organizing principle. Candidate techniques were identified through a comprehensive review of self-determination theory interventions and nomination by experts. The study team developed a preliminary list of candidate techniques accompanied by labels, definitions, and function descriptions of each. Each technique was aligned with the most closely-related psychological need satisfaction construct (autonomy, competence, or relatedness). Using an iterative expert consensus procedure, participating experts (N=18) judged each technique on the preliminary list for redundancy, essentiality, uniqueness, and the proposed link between the technique and basic psychological need. The procedure produced a final classification of 21 motivation and behavior change techniques (MBCTs). Redundancies between final MBCTs against techniques from existing behavior change technique taxonomies were also checked. The classification system is the first formal attempt to systematize self-determination theory intervention techniques. The classification is expected to enhance consistency in descriptions of self-determination theory-based interventions in health contexts, and assist in facilitating synthesis of evidence on interventions based on the theory. The classification is also expected to guide future efforts to identify, describe, and classify the techniques that comprise self-determination theory-based interventions in multiple domains.
Text messages remain a preferred way for adolescents to communicate, and recent evidence suggests adolescents would like access to digital healthcare options. However, there is limited evidence for text messages to engage adolescent populations in obesity prevention behaviors. We aimed to co-design a bank of text messages that are evidence-based, acceptable, and engaging for adolescents. An established iterative mixed methods process, consisting of three phases, was used to develop the text message program. The first bank of 145 text messages was drafted based on current evidence, behavior change techniques, and input from researchers and health professionals. A survey was then administered to adolescents and professionals for review of text message content, usefulness, understanding, and age-appropriateness. An adolescent research assistant collaborated with the research team on all three phases. Forty participants (25 adolescents and 15 professionals) reviewed the initial bank of 145 text messages. On average, all reviewers agreed the text messages were easy to understand (13.6/15) and useful (13.1/15). In total, 107 text messages were included in the final text message bank to support behavior change and prevent obesity. This study may guide other researchers or health professionals who are seeking to engage adolescents in the co-design of health promotion or intervention content. Effectiveness of the text message program will be tested in a randomized controlled trial.
Background:
Lifestyle modifications represent the first line of treatment in obesity management; however, many adolescents with obesity do not meet lifestyle recommendations. Given that adolescents are rarely consulted during health policy development and in the design of lifestyle interventions, their first-hand experiences, preferences, and priorities may not be represented. Accordingly, our purpose was to explore adolescents' lifestyle treatment recommendations to inform policy and program decisions.
Methods:
Conducted from July 2017 to January 2018, this study adhered to a qualitative, crosslanguage, patient-oriented design. We recruited 19 13-17-year-old adolescents (body mass index [BMI] ≥85th percentile) seeking multidisciplinary treatment for obesity in geographically and culturally diverse regions of Canada. Adolescents participated in one-on-one, in-person, semi-structured interviews in English or French. Interviews were audio-recorded, transcribed verbatim, managed using NVivo 11, and analyzed using quantitative and qualitative content analysis by two independent researchers.
Results:
Adolescents' recommendations were organized into five categories, each of which denotes health as a collective responsibility: (i) establish parental support within limits, (ii) improve accessibility and availability of 'healthy foods', (iii) limit deceptive practices in food marketing, (iv) improve accessibility and availability of varied physical activity opportunities, and (v) delay school start times. Respect for individual autonomy and decision-making capacity were identified as particularly important, however these were confronted with adolescents' partial knowledge on nutrition and food literacy.
Conclusions:
Adolescents' recommendations highlighted multi-level, multi-component factors that influenced their ability to lead healthy lifestyles. Uptake of these recommendations by policy-makers and program developers may be of added value for lifestyle treatment targeting adolescents with obesity.
Objective: Behavioral interventions for adolescent weight control are often difficult to access because they are rarely provided in primary health care. This study was designed to assess the feasibility, acceptability, and preliminary effectiveness of a motivational interviewing plus adaptive text messaging intervention for adolescent weight control delivered in primary care. Methods: Forty-seven overweight adolescents (aged 13–18 years) participated in a single, hour-long, in-person motivational interviewing session in their primary care pediatrician’s office with a clinical psychology doctoral student. All participants monitored diet, physical activity, and weight over 6 months and reported this information nightly via text message. Participants were selected randomly to receive computer-tailored adaptive text messages 3 times per day at mealtimes as an additional intervention component. Results: Participants found the intervention to be acceptable and beneficial for promoting weight-related behavior change. Adherence to self-monitoring was significantly higher in the adaptive text messaging group. Although body mass index z-score (zBMI) change was not significantly different across treatment groups, participants receiving the adaptive text message intervention demonstrated a reduction of .32 zBMI standard deviation units from before to after intervention, t(28) = −2.84, p < .01, d = .54, whereas zBMI did not change for individuals receiving the control intervention. Several domains of weight-related quality of life improved during the intervention period irrespective of treatment assignment. Conclusions: Study findings suggest that a behavioral weight control intervention delivered in a primary care is acceptable/feasible and may produce reductions in zBMI. Fully powered studies to further evaluate this intervention approach are warranted.
Obesity is one of the greatest health challenges facing today’s adolescents. Dietary interventions are the foundation of obesity prevention and management. As adolescents are digital frontrunners and early adopters of technology, digital health interventions appear the most practical modality for dietary behavior change interventions. Despite the rapid growth in digital health interventions, effective engagement with adolescents remains a pertinent issue. Key strategies for effective engagement include co-designing interventions with adolescents, personalization of interventions, and just-in-time adaptation using data from wearable devices. The aim of this paper is to appraise these strategies, which may be used to improve effective engagement and thereby improve the dietary behaviors of adolescents now and in the future.
Background:
The use of text messages (short message service, SMS) to change physical activity and sedentary behavior in youth is of interest due to the need for novel, more effective intervention approaches. Previous reviews have examined a variety of technology-based interventions and their impact on different health behaviors, but evidence regarding the impact of just SMS on physical activity and sedentary behavior is lacking.
Objective:
The aim of this study was to assess the effectiveness and use of theory of SMS interventions for improving physical activity and sedentary behavior in youth.
Methods:
Authors systematically searched electronic databases from March to November 2017. Citations were sifted using additional reviewers, and a qualitative synthesis of eligible studies was conducted using piloted data extraction forms. To be eligible for inclusion, studies had to be of a randomized controlled or quasi-experimental design, incorporate SMS, involve adolescents between the ages of 10 and 19 years, and assess at least one physical activity or sedentary behavior outcome. Risk of bias was assessed using the Cochrane Collaboration's Risk of Bias tool.
Results:
A total of 13 studies reporting 11 interventions were included in the qualitative analysis. Studies included interventions that were conducted in schools, online, or face-to-face. Studies were of high heterogeneity with regard to study duration, participant characteristics, intervention content, and outcome measures. Findings were equivocal with regard to intervention effectiveness for physical activity and sedentary behavior. Overall, 7 interventions resulted in an improvement for physical activity and 6 for sedentary behavior. All studies were judged to be of high risk of bias for at least 1 item.
Conclusions:
Some studies in this review showed promising results for using SMS to improve physical activity and sedentary behavior in youth. High heterogeneity of design and outcome measures precluded data pooling and conclusions as to which specific intervention elements are linked to increased effectiveness cannot be drawn. The authors propose incorporating the following elements in future studies: specific focus on desired health behavior; mixed-methods design; include long-term follow-up; include self-monitoring, goal setting, and feedback; combine SMS with a mobile app; and send 3 or more SMS text messages per week. More rigorous studies are needed to explore the relationship between intervention effectiveness and specific intervention components such as content and delivery.
Background:
In the United States, approximately one-third of adolescents are now overweight or obese, and one in six is obese. This financial cost and the larger nonfinancial costs of obesity make obesity prevention and management for adolescents imperative for the health of the nation. However, primary care visits are typically brief, and primary care providers may lack adequate resources to help overweight or obese adolescents to manage weight issues. To augment the efficacy of primary care visits for adolescent weight management, mobile phone technology can be used as an adjunct treatment that provides additional opportunities for encouraging improvement in lifestyle, attainment, and maintenance of healthy weight.
Objective:
The purposes of this study were to (1) measure effects of an innovative mobile phone technology-based intervention for overweight and obese adolescents and to (2) examine the intervention's feasibility for use in primary care clinics.
Methods:
The mobile phone-based intervention had three components: use of the Fitbit Flex, participation in an online educational program, and receipt of biweekly text messages during the maintenance phase. A randomized controlled study design was utilized. Data regarding anthropometrics (body mass index [BMI] and waist-to-hip ratio), blood pressure, levels of physical and sedentary activity, diet, and self-efficacy regarding physical activity and diet were collected at baseline and at 3 and 6 months after the baseline assessment.
Results:
A total of 40 adolescents participated in the study. At the 6-month follow-up visit, compared to participants in the control group, the mobile phone-based intervention participants had significant improvement in BMI (z=-4.37, P=.001), diastolic blood pressure (z=-3.23, P=.001), physical activity days per week (z=2.58, P=.01), TV and computer time (z=-3.34, P=.001), servings of fruits and vegetables per day (z=2.74, P=.006), servings of soda and sweetened drinks (z=-3.19, P=.001), physical activity self-efficacy (z=2.75, P=.006), and dietary self-efficacy (z=5.05, P=.001). Medium to large effect sizes were found in these outcome variables.
Conclusions:
The use of mobile technologies may offer a practical, reliable adjunct to weight management for overweight and obese adolescents in busy primary care clinics serving adolescents.
Trial registration:
Clinicaltrials.gov NCT 01693250; https://clinicaltrials.gov/ct2/show/NCT01693250? term=Adolescent+ obesity+AND+mhealth&rank=5 (Archived by WebCite at ).
In conventional randomised controlled trials (RCTs), researchers design the interventions. In the Camino Verde trial, each intervention community designed its own programmes to prevent dengue. Instead of fixed actions or menus of activities to choose from, the trial randomised clusters to a participatory research protocol that began with sharing and discussing evidence from a local survey, going on to local authorship of the action plan for vector control.
Adding equitable stakeholder engagement to RCT infrastructure anchors the research culturally, making it more meaningful to stakeholders. Replicability in other conditions is straightforward, since all intervention clusters used the same engagement protocol to discuss and to mobilize for dengue prevention. The ethical codes associated with RCTs play out differently in community-led pragmatic trials, where communities essentially choose what they want to do. Several discussion groups in each intervention community produced multiple plans for prevention, recognising different time lines. Some chose fast turnarounds, like elimination of breeding sites, and some chose longer term actions like garbage disposal and improving water supplies.
A big part of the skill set for community-led trials is being able to stand back and simply support communities in what they want to do and how they want to do it, something that does not come naturally to many vector control programs or to RCT researchers. Unexpected negative outcomes can come from the turbulence implicit in participatory research. One example was the gender dynamic in the Mexican arm of the Camino Verde trial. Strong involvement of women in dengue control activities seems to have discouraged men in settings where activity in public spaces or outside of the home would ordinarily be considered a “male competence”.
Community-led trials address the tension between one-size-fits-all programme interventions and local needs. Whatever the conventional wisdom about how prevention works at a system level, programmes have to be perceived as locally relevant and they must engage stakeholders who make them work. Locally, each participating community has to know the intervention is relevant to them; they have to want to do it. That happens much more easily if they design the programme themselves.
Background
Although many wearable devices for monitoring and tracking physical activity are available to consumers, relatively few research studies have been conducted to determine their efficacy in promoting health.
Methods
In this article, data on the use of consumer wearable devices in promoting healthy behaviors are summarized based upon bibliographic searches in PubMed and Psychology and Behavioral Sciences Collection with relevant search terms through September 2016.
Results
A total of 274 articles were identified in the bibliographic searches. By screening abstracts or full-text articles, six pre/post test trials and seven randomized controlled trials were identified. In initial trials, consumer wearable devices have been shown to increase physical activity and help users lose weight. However, the number of studies completed to date is small and limited by small sample sizes, short study durations, and uncertain generalizability of the findings.
Conclusions
Future studies should utilize randomized controlled trial research designs, larger sample sizes, and longer study periods to better establish the efficacy of wearable devices in promoting physical activity. Additional research is needed to determine the feasibility and effectiveness of wearable devices in promoting physical activity and weight loss in community settings including communities affected by health disparities. Studies focusing on children and adolescents are also needed.
Background
The proliferation and popularity of wearable activity trackers (eg, Fitbit, Jawbone, Misfit) may present an opportunity to integrate such technology into physical activity interventions. While several systematic reviews have reported intervention effects of using wearable activity trackers on adults’ physical activity levels, none to date have focused specifically on children and adolescents.
Objective
The aim of this review was to examine the effectiveness of wearable activity trackers as a tool for increasing children’s and adolescents’ physical activity levels. We also examined the feasibility of using such technology in younger populations (age range 5-19 years).
Methods
We conducted a systematic search of 5 electronic databases, reference lists, and personal archives to identify articles published up until August 2016 that met the inclusion criteria. Articles were included if they (1) specifically examined the use of a wearable device within an intervention or a feasibility study; (2) included participants aged 5-19 years old; (3) had a measure of physical activity as an outcome variable for intervention studies; (4) reported process data concerning the feasibility of the device in feasibility studies; and (5) were published in English. Data were analyzed in August 2016.
Results
In total, we identified and analyzed 5 studies (3 intervention, 2 feasibility). Intervention delivery ranged from 19 days to 3 months, with only 1 study using a randomized controlled trial design. Wearable activity trackers were typically combined with other intervention approaches such as goal setting and researcher feedback. While intervention effects were generally positive, the reported differences were largely nonsignificant. The feasibility studies indicated that monitor comfort and design and feedback features were important factors to children and adolescents.
Conclusions
There is a paucity of research concerning the effectiveness and feasibility of wearable activity trackers as a tool for increasing children’s and adolescents’ physical activity levels. While there are some preliminary data to suggest these devices may have the potential to increase activity levels through self-monitoring and goal setting in the short term, more research is needed to establish longer-term effects on behavior.
Smartphones are used ubiquitously worldwide and are essential tools in modern society. However, smartphone overuse is an emerging social issue, and limited studies have objectively assessed this matter. The majority of previous studies have included surveys or behavioral observation studies. Since a previous study demonstrated an association between increased push notifications and smartphone overuse, we investigated the effects of push notifications on task performance. We detected changes in brainwaves generated by smartphone push notifications using the N200 and P300 components of event-related potential (ERP) to investigate both concentration and cognitive ability. ERP assessment indicated that, in both risk and nonrisk groups, the lowest N200 amplitude and the longest latency during task performance were found when push notifications were delivered. Compared to the nonrisk group, the risk group demonstrated lower P300 amplitudes and longer latencies. In addition, the risk group featured a higher rate of error in the Go-Nogo task, due to the negative influence of smartphone push notifications on performance in both risk and nonrisk groups. Furthermore, push notifications affected subsequent performance in the risk group.
Background: Mobile health (mHealth) has been posited to contribute to the reduction in health gaps and has shown fast and widespread growth in developing countries. This growth demands understanding of, and preparedness for, local cultural contexts.
Objective: To describe the design and validation of text messages (short message service, SMS) that will be used for an mHealth behavioral change intervention to prevent hypertension in three Latin American countries: Argentina, Guatemala, and Peru.
Methods: An initial set of 64 SMS text messages were designed to promote healthy lifestyles among individuals in different stages of behavior change, addressing four key domains: salt and sodium intake, fruit and vegetable intake, consumption of high fat and sugar foods, and physical activity. The 64 SMS text messages were organized into nine subsets for field validation. In each country 36 people were recruited, half of them being male. Of the participants, 4 per country evaluated each subset of SMS text messages, which contained between 6 and 8 SMS text messages regarding different key domains and stages of change. The
understanding and appeal of each SMS text message was assessed using a 7-item questionnaire. The understanding and appeal ratings were used to reach a final set of 56 SMS text messages.
Results: Overall, each of the 64 SMS text messages received a total of 12 evaluations (4 per country). The majority of evaluations—742 out of a total of 767 (96.7%) valid responses—revealed an adequate understanding of the key idea contained in the SMS text message. On a scale from 1 to 10, the average appeal score was 8.7 points, with a range of 4 to 10 points. Based on their low scores, 8 SMS text messages per country were discarded. Once the final set of 56 SMS text messages was established, and based on feedback obtained in the field, wording and content of some SMS text messages were improved. Of the final set, 9, 8, and 16 of the SMS text messages were improved based on participant evaluations from Argentina, Guatemala, and Peru, respectively. Most SMS text messages selected for the final set (49/56, 88%) were the same in all countries, except for small wording differences.
Conclusions: The final set of SMS text messages produced had very high rates of understanding and appeal in three different Latin American countries. This study highlights the importance of developing and validating a package of simple, preventative SMS text messages, grounded in evidence and theory, across three different Latin American countries with active engagement of end users.
Background:
School-based health centers (SBHCs) may be an ideal setting to address obesity in adolescents because they provide increased access to a traditionally difficult-to-reach population. The study evaluated the feasibility of adding a health educator (HE) to SBHC teams to provide support and increase the delivery of preventive services for overweight or obese adolescents.
Methods:
Adolescents with BMI ≥85% recruited from two SBHCs were randomized to a control group (CG) or an intervention group (IG). Both groups received preventive services, including physical examinations and laboratory screening in the SBHC. The educator met with the IG during the academic year, utilizing motivational interviewing techniques to set lifestyle goals. Text messaging was used to reinforce goals between visits.
Results:
Eighty-two students (15.7±1.5 years of age; BMI, 31.9±6.2 kg/m(2)) were enrolled in the IG and 83 in the control group (16.0±1.5 years of age; BMI, 31.6±6.5 kg/m(2)). Retention was 94% in the IG and 87% in the CG. A total of 54.5% of the IG and 72.2% of the CG decreased or maintained BMI z-score (less than 0.05 increase; p=0.025). Sports participation was higher in the CG (47% vs. 28% in the IG; p=0.02). Mean BMI z-score change was -0.05±0.2 for students participating in sports vs. 0.01±0.2 for those not (p=0.09).
Conclusions:
This SBHC intervention showed successful recruitment and retention of participants and delivery of preventive services in both groups. Meeting with an HE did not improve BMI outcomes in the IG. Confounding factors, including sports participation and SBHC utilization, likely contributed to BMI outcomes.
Background
Adolescents and young adults use text messaging as their primary mode of communication, thus providing an opportunity to use this mode of communication for mobile health (mHealth) interventions. Youth with diabetes are an important group for these mHealth initiatives, as diabetes management requires an enormous amount of daily effort and this population has difficulty achieving optimal diabetes management. Goal setting and self-efficacy are 2 factors in the management of diabetes. We examined the feasibility of a healthy lifestyle text messaging program targeting self-efficacy and goal setting among adolescents and young adults with diabetes.
Methods
Participants, ages 16-21, were assigned to either a text messaging group, which received daily motivational messages about nutrition and physical activity, or a control group, which received paper-based information about healthy lifestyle. Both groups set goals for nutrition and physical activity and completed a measure of self-efficacy.
Results
Participants’ mean age was 18.7 ± 1.6 years old, with diabetes duration of 10.0 ± 4.6 years, and A1c of 8.7 ± 1.7%. The text messaging intervention was rated highly and proved to be acceptable to participants. Self-efficacy, glycemic control, and body mass index did not change over the course of the short, 1-month pilot study.
Conclusions
Positive, daily, motivational text messages may be effective in increasing motivation for small goal changes in the areas of nutrition and physical activity. These interventions may be used in the future in youth with diabetes to improve diabetes care. Utilizing more targeted text messages is an area for future research.
Background:
Electronic activity monitors (such as those manufactured by Fitbit, Jawbone, and Nike) improve on standard pedometers by providing automated feedback and interactive behavior change tools via mobile device or personal computer. These monitors are commercially popular and show promise for use in public health interventions. However, little is known about the content of their feedback applications and how individual monitors may differ from one another.
Objective:
The purpose of this study was to describe the behavior change techniques implemented in commercially available electronic activity monitors.
Methods:
Electronic activity monitors (N=13) were systematically identified and tested by 3 trained coders for at least 1 week each. All monitors measured lifestyle physical activity and provided feedback via an app (computer or mobile). Coding was based on a hierarchical list of 93 behavior change techniques. Further coding of potentially effective techniques and adherence to theory-based recommendations were based on findings from meta-analyses and meta-regressions in the research literature.
Results:
All monitors provided tools for self-monitoring, feedback, and environmental change by definition. The next most prevalent techniques (13 out of 13 monitors) were goal-setting and emphasizing discrepancy between current and goal behavior. Review of behavioral goals, social support, social comparison, prompts/cues, rewards, and a focus on past success were found in more than half of the systems. The monitors included a range of 5-10 of 14 total techniques identified from the research literature as potentially effective. Most of the monitors included goal-setting, self-monitoring, and feedback content that closely matched recommendations from social cognitive theory.
Conclusions:
Electronic activity monitors contain a wide range of behavior change techniques typically used in clinical behavioral interventions. Thus, the monitors may represent a medium by which these interventions could be translated for widespread use. This technology has broad applications for use in clinical, public health, and rehabilitation settings.
Understanding children's physical activity motivation, its antecedents and associations with behavior is important and can be advanced by using self-determination theory. However, research among youth is largely restricted to adolescents and studies of motivation within certain contexts (e.g., physical education). There are no measures of self-determination theory constructs (physical activity motivation or psychological need satisfaction) for use among children and no previous studies have tested a self-determination theory-based model of children's physical activity motivation. The purpose of this study was to test the reliability and validity of scores derived from scales adapted to measure self-determination theory constructs among children and test a motivational model predicting accelerometer-derived physical activity.
Cross-sectional data from 462 children aged 7 to 11 years from 20 primary schools in Bristol, UK were analysed. Confirmatory factor analysis was used to examine the construct validity of adapted behavioral regulation and psychological need satisfaction scales. Structural equation modelling was used to test cross-sectional associations between psychological need satisfaction, motivation types and physical activity assessed by accelerometer.
The construct validity and reliability of the motivation and psychological need satisfaction measures were supported. Structural equation modelling provided evidence for a motivational model in which psychological need satisfaction was positively associated with intrinsic and identified motivation types and intrinsic motivation was positively associated with children's minutes in moderate-to-vigorous physical activity.
The study provides evidence for the psychometric properties of measures of motivation aligned with self-determination theory among children. Children's motivation that is based on enjoyment and inherent satisfaction of physical activity is associated with their objectively-assessed physical activity and such motivation is positively associated with perceptions of psychological need satisfaction. These psychological factors represent potential malleable targets for interventions to increase children's physical activity.
During the last 30 years several theories of motivation have generated insights into the motives underlying learners’ behavior in physical education. Self-Determination Theory (SDT), a general theory on social development and motivation, has enjoyed increasing popularity in physical education research during the past decade. SDT states that for students to be optimally motivated for physical education, it is critical to support the satisfaction of their innate, psychological needs for autonomy, competence, and relatedness by being autonomy supportive, by structuring the environment and by creating a warm and solid relationship with the students.
Purpose: Our goal was to provide a critical review of 74 SDT-grounded peer-reviewed studies in the field of physical education, to identify research gaps, and to provide suggestions for moving this line of research forward by discussing how insights from a pedagogical view can contribute to the development of SDT-based research.
Findings: The included studies confirmed the motivational sequence as proposed by SDT. It was revealed that future research can be of extra value if a) combinations of the three dimensions of need supportive practices are addressed, b) more intervention and experimental studies are conducted, c) more insight is gained into antecedents of teachers’ behaviors, d) a broader set of learning outcomes is investigated, and e) relevant physical education related contextual factors are taken into account.
Conclusions: Given the increasing number of SDT-studies in the context of physical education, this review recommends a better integration of pedagogical and psychological knowledge in future SDT-grounded work in the context of physical education. A better integration is needed because it can lead to ecologically valid and practical recommendations on how to enhance students’ motivation taking into account the pedagogical context of physical education.
Obese adolescents are at risk for type 2 diabetes mellitus (T2DM). Obesity interventions delivered through media, such as the web and text messages [short message service (SMS)] may be beneficial when targeting obese adolescents..
A randomized controlled trial, Pace-Internet for Diabetes Prevention Intervention (PACEi-DP), compared three forms of an obesity intervention to usual care (UC): (a) website only (W); (b) website, monthly group sessions, and follow-up calls (WG); and (c) website and SMS (WSMS). Participants were overweight or obese adolescents at risk for T2DM (n = 101; age 12-16 years; mean body mass index (BMI) percentile = 97.6; 74.3% Hispanic). In addition to the website, WSMS participants received SMS supporting intervention goals and behavioral strategies and communicated via SMS with a case manager. WG participants had additional group activities related to weight loss and received follow-up calls from a health coach. UC participants were given printed materials and encouraged to attend three initial group sessions. Repeated measures mixed model regression analyses tested treatment effects for anthropometric, behavioral, and behavioral change strategy outcomes.
There were no treatment effects for BMI, adiposity, physical activity, or diet at 12 months. Treatment effects were observed for sedentary behavior, with the W arm having a greater decrease in sedentary behavior (4.9 to 2.8 h/day) than the UC arm (p = .006).
Although not sufficient to produce weight loss, the combination of web intervention and group sessions with telephone follow-up yielded improvements in sedentary behavior and in the use of behavior change strategies expected to lead to behavior change.
Thematic analysis is a poorly demarcated, rarely acknowledged, yet widely used qualitative analytic method within psychology. In this paper, we argue that it offers an accessible and theoretically flexible approach to analysing qualitative data. We outline what thematic analysis is, locating it in relation to other qualitative analytic methods that search for themes or patterns, and in relation to different epistemological and ontological positions. We then provide clear guidelines to those wanting to start thematic analysis, or conduct it in a more deliberate and rigorous way, and consider potential pitfalls in conducting thematic analysis. Finally, we outline the disadvantages and advantages of thematic analysis. We conclude by advocating thematic analysis as a useful and flexible method for qualitative research in and beyond psychology.
Self-determination theory (SDT) is an empirically based theory of human motivation, development, and wellness. The theory focuses on types, rather than just amount, of motivation, paying particular attention to autonomous motivation, controlled motivation, and amotivation as predictors of performance, relational, and well-being outcomes. It also addresses the social conditions that enhance versus diminish these types of motivation, proposing and finding that the degrees to which basic psychological needs for autonomy, competence, and relatedness are supported versus thwarted affect both the type and strength of motivation. SDT also examines people's life goals or aspirations, showing differential relations of intrinsic versus extrinsic life goals to performance and psychological health. In this introduction we also briefly discuss recent developments within SDT concerning mindfulness and vitality, and highlight the applicability of SDT within applied domains, including work, relationships, parenting, education, virtual environments, sport, sustainability, health care, and psychotherapy.
Motivation is a critical factor in supporting sustained exercise, which in turn is associated with important health outcomes. Accordingly, research on exercise motivation from the perspective of self-determination theory (SDT) has grown considerably in recent years. Previous reviews have been mostly narrative and theoretical. Aiming at a more comprehensive review of empirical data, this article examines the empirical literature on the relations between key SDT-based constructs and exercise and physical activity behavioral outcomes.
This systematic review includes 66 empirical studies published up to June 2011, including experimental, cross-sectional, and prospective studies that have measured exercise causality orientations, autonomy/need support and need satisfaction, exercise motives (or goal contents), and exercise self-regulations and motivation. We also studied SDT-based interventions aimed at increasing exercise behavior. In all studies, actual or self-reported exercise/physical activity, including attendance, was analyzed as the dependent variable. Findings are summarized based on quantitative analysis of the evidence.
The results show consistent support for a positive relation between more autonomous forms of motivation and exercise, with a trend towards identified regulation predicting initial/short-term adoption more strongly than intrinsic motivation, and intrinsic motivation being more predictive of long-term exercise adherence. The literature is also consistent in that competence satisfaction and more intrinsic motives positively predict exercise participation across a range of samples and settings. Mixed evidence was found concerning the role of other types of motives (e.g., health/fitness and body-related), and also the specific nature and consequences of introjected regulation. The majority of studies have employed descriptive (i.e., non-experimental) designs but similar results are found across cross-sectional, prospective, and experimental designs.
Overall, the literature provides good evidence for the value of SDT in understanding exercise behavior, demonstrating the importance of autonomous (identified and intrinsic) regulations in fostering physical activity. Nevertheless, there remain some inconsistencies and mixed evidence with regard to the relations between specific SDT constructs and exercise. Particular limitations concerning the different associations explored in the literature are discussed in the context of refining the application of SDT to exercise and physical activity promotion, and integrating these with avenues for future research.
This paper reports the final 24-month outcomes of a randomized controlled trial evaluating the effect of additional therapeutic contact (ATC) as an adjunct to a community-based weight-management program for overweight and obese 13-16-year-olds. ATC involved telephone coaching or short-message-service and/or email communication once per fortnight. Adolescents were randomized to receive the Loozit group program-a two-phase behavioral lifestyle intervention with (n=73), or without (n=78), ATC in Phase 2. Adolescents/parents separately attended seven weekly group sessions (Phase 1), followed by quarterly adolescent sessions (Phase 2). Assessor-blinded, 24-month changes in anthropometry and metabolic health included primary outcomes body mass index (BMI) z-score and waist:height ratio (WHtR). Secondary outcomes were self-reported psychosocial and lifestyle changes. By 24 months, 17 adolescents had formally withdrawn. Relative to the Loozit program alone, ATC largely had no impact on outcomes. Secondary pre-post assessment of the Loozit group program showed mean (95% CI) reductions in BMI z-score (-0.13 (-0.20, -0.06)) and WHtR (-0.02 (-0.03, -0.01)) in both arms, with several metabolic and psychosocial improvements. Adjunctive ATC did not provide further benefits to the Loozit group program. We recommend that further work is needed to optimize technological support for adolescents in weight-loss maintenance. Australian New Zealand Clinical Trials Registry Number ACTRNO12606000175572.International Journal of Obesity advance online publication, 15 May 2012; doi:10.1038/ijo.2012.74.
Teens do not meet guidelines for healthy eating and physical activity. The Internet may be an effective method for delivering programs that help them adopt healthy behaviors.
To collect information to design content and structure for a teen-friendly website promoting healthy eating and physical activity behaviors.
Qualitative research, encompassing both focus group and interview techniques, were used to design the website. Participants were 12-17 year olds in Houston, Texas, and West Lafayette, Indiana.
A total of 133 participants took part in 26 focus groups while 15 participated in one-on-one interviews to provide guidance for the development of teen-friendly content and structure for an online behavior change program promoting healthy eating and physical activity to 12-17 year olds. The youth made suggestions to overcome common barriers to healthy eating and physical activity. Their feedback was used to develop "Teen Choice: Food & Fitness," a 12-week online behavior change program, populated by 4 cartoon character role models.
It is critical that members of the target audience be included in formative research to develop behavior change programs that are relevant, appealing, and address their needs and interests.
To assess the outcomes of the Loozit adolescent weight management intervention and to evaluate the effect of additional therapeutic contact 12 months into the program.
A 24-month, 2-arm randomized controlled trial. Results at 12 months are presented.
Community health center and children's hospital in Sydney, Australia.
A total of 151 overweight or obese 13- to 16-year-olds.
In the first 2 months (phase 1), participants received 7 adolescent and parent weekly sessions focused on lifestyle modification. From 2 to 24 months (phase 2), adolescents attended booster sessions once every 3 months. During phase 2, adolescents randomized to the additional therapeutic contact arm also received telephone coaching and electronic communications once every 2 weeks.
Baseline to 12-month changes in body mass index z score and waist to height ratio (primary outcomes) and changes in metabolic, psychosocial, and behavioral variables.
Of 151 randomized adolescents, 82.1% completed 12-month follow-up. Intent-to-treat analyses showed significant reductions in mean body mass index z score (-0.09; 95% CI, -0.12 to -0.06), waist to height ratio (-0.02; 95% CI, -0.03 to -0.01), total cholesterol level (-4 mg/dL; 95% CI, -8 to 0 mg/dL; to convert to millimoles per liter, multiply by 0.0259), and triglycerides level (geometric mean, -80 mg/dL; 95% CI, -88 to -71 mg/dL; to convert to millimoles per liter, multiply by 0.0113). Most psychosocial outcomes improved, including global self-worth, but there were few dietary, physical activity, or sedentary behavior changes. No difference was found in primary outcomes between participants who did or did not receive additional therapeutic contact.
The Loozit randomized controlled trial produced a significant but modest reduction in body mass index z score and improved psychosocial outcomes at 12 months. Supplementary telephone and electronic contact provided no additional benefit at 12 months. Trial Registration anzctr.org.au Identifier: 12606000175572.
In the past decade, there has been no systematic review of the evidence for maintenance of physical activity and/or dietary behavior change following intervention (follow-up). This systematic review addressed three questions: 1) How frequently do trials report on maintenance of behavior change? 2) How frequently do interventions achieve maintenance of behavior change? 3) What sample, methodologic, or intervention characteristics are common to trials achieving maintenance?
Systematic review of trials that evaluated a physical activity and/or dietary behavior change intervention among adults, with measurement at preintervention, postintervention, and at least 3 months following intervention completion (follow-up).
Maintenance of behavior change was defined as a significant between-groups difference at postintervention and at follow-up, for one or more physical activity and/or dietary outcome.
Maintenance outcomes were reported in 35% of the 157 intervention trials initially considered for review. Of the 29 trials that met all inclusion criteria, 21 (72%) achieved maintenance. Characteristics common to trials achieving maintenance included those related to sample characteristics (targeting women), study methods (higher attrition and pretrial behavioral screening), and intervention characteristics (longer duration [>24 weeks], face-to-face contact, use of more intervention strategies [>6], and use of follow-up prompts).
Maintenance of physical activity and dietary behavior change is not often reported; when it is, it is often achieved. To advance the evidence, the field needs consensus on reporting of maintenance outcomes, controlled evaluations of intervention strategies to promote maintenance, and more detailed reporting of interventions.
Parent-report and child perception of familial support for weight-related behaviors may not be congruent. This research explores whether parent-report or child perception is more strongly associated with child-reported physical activity and television (TV) use.
Elementary school children (n = 73) participating in Ready. Set. ACTION!, a theater-based obesity prevention pilot program in Saint Paul, MN, and their parents completed surveys assessing familial support for physical activity and limitations on TV use in fall 2006. Paired t tests examined congruency between parent-report and child perception. Linear regression models adjusted for sociodemographics explored the associations between familial support and child-reported behavior.
Levels of agreement between parent-report and child perception for support for physical activity and limitations on TV use were approximately 70%. Compared with parent-report for physical activity support, child perception was more strongly associated with child physical activity (beta = .17, P = .02). Neither parent-report nor child perception for support for limitations on TV use was associated with child TV use.
Although parent-report and child perception of familial support for physical activity and to limit TV use were similar, child perception was more strongly associated with child physical activity behavior. More research, probably qualitative, is needed to examine how parents and children define and perceive parental support.
Type 2 diabetes has increased in prevalence among youth, paralleling the increase in pediatric obesity. Helping youth achieve energy balance by changing diet and physical activity behaviors should decrease the risk for type 2 diabetes and obesity. Goal setting and goal review are critical components of behavior change. Theory-informed video games that emphasize development and refinement of goal setting and goal review skills provide a method for achieving energy balance in an informative, entertaining format. This article reports alpha-testing results of early versions of theory-informed goal setting and reviews components of two diabetes and obesity prevention video games for preadolescents.
Two episodes each of two video games were alpha tested with 9- to 11-year-old youth from multiple ethnic groups. Alpha testing included observed game play followed by a scripted interview. The staff was trained in observation and interview techniques prior to data collection.
Although some difficulties were encountered, alpha testers generally understood goal setting and review components and comprehended they were setting personal goals. Although goal setting and review involved multiple steps, youth were generally able to complete them quickly, with minimal difficulty. Few technical issues arose; however, several usability and comprehension problems were identified.
Theory-informed video games may be an effective medium for promoting youth diabetes and obesity prevention. Alpha testing helps identify problems likely to have a negative effect on functionality, usability, and comprehension during development, thereby providing an opportunity to correct these issues prior to final production.
Health behavior interventions using periodic prompts have utilized technology, such as the Internet, that allows messages to be sent to participants in cost-effective ways. To our knowledge, no comprehensive evidence review has been performed specifically to evaluate the effectiveness of communicating regular messages and to examine how characteristics of the prompts change the effectiveness of programs aimed at reminding people to adopt healthy behaviors, maintain those they already practice, and cease unhealthy behaviors.
A systematic literature review was performed to investigate the effectiveness of limited contact interventions targeting weight loss, physical activity, and/or diet that provided periodic prompts regarding behavior change for health promotion. The review sought to identify specific characteristics of these interventions that may be associated with superior results.
Electronic literature searches were performed between February and April, 2008. Articles were included if periodic prompts were used as an intervention or a component of an intervention, a behavioral or biological outcome measure was used, and an ongoing health promotion behavior was targeted. A rating system was applied to each study to provide a quantitative representation of the quality of the evidence provided by each article.
There were 19 articles with a combined sample size of 15,655 that met the inclusion criteria, and 11 studies reported positive findings regarding the utility of periodic prompts. Several articles showed enhanced effectiveness when prompts were frequent and personal contact with a counselor was included. Long-term behavior change and health improvements were not examined by this review because of a lack of long-term follow-up in the literature.
In light of promising results of most studies, additional research on limited contact interventions targeting health behaviors including weight loss, physical activity, and/or diet is merited that utilizes rigorous methods including control groups; follow-up data collection; and testing of prompt frequencies, specific intervention components, or prompt characteristics. Future research would be especially valuable if it improves understanding of the most effective types of periodic prompts for fostering long-term behavior change in order to maximize use of this tool in limited contact health promotion programs. Specifically, various types of communication technology should be used and evaluated to expand and refine their use.
Background:
Poor physical activity (PA) and sleep behaviors in Hispanic adolescents contributes to increased risk for type 2 diabetes. Commonly owned digital devices and services like smartphones and text-messaging are highly used among adolescents and are promising intervention tools for reaching this age group. Personal activity trackers assess activity and sleep, making them ideal tools for addressing these behaviors. We propose to examine the feasibility of a 12-week intervention that uses theoretically grounded text messages and a Fitbit device to improve PA and sleep among Hispanic adolescents with obesity, as compared to a wait-list control group with a Fitbit device only.
Methods:
Participants (N = 48; 14-16 years) will be randomized (1:1) to the intervention or wait-list control group. Youth in the intervention will receive a Fitbit Charge 5 and daily text messages. Youth in the wait-list control group will receive a Fitbit Charge 5 and information on PA and sleep guidelines.
Results:
Feasibility will be examined by collecting process evaluation data on the following criteria: (1) recruit 48 Hispanic adolescents 14-16 years; (2) retain 85% of participants for post-assessments; (3) Fitbit wear ≥4 days/week and respond to 80% of text messages when prompted; (4) ≤10% technical issues; and (5) obtain 80% satisfaction from participants.
Discussion:
This study will advance our knowledge on the feasibility of digital prevention strategies to promote PA and sleep behaviors to reduce T2D risk among Hispanic youth. If feasible, this approach has the potential to be a scalable, cost-effective diabetes prevention strategy among high-risk youth.
Trial registration:
NCT04953442, registered on July 8, 2021.
This cross-sectional study assesses trends in the prevalence of obesity in children and adolescents in the US between 2011 and 2020.
Introduction
The rates of pediatric obesity in the U.S. are highest among Hispanics. There is no existing meta-analysis of the effects of obesity interventions among Hispanic youth. This systematic review and meta-analysis assesses the effects of obesity prevention and treatment interventions on Hispanic youth's weight status and lifestyle behaviors.
Methods
PubMed, PsycINFO, and Scopus were searched between January 1, 2000 and October 30, 2020. Interventions with ≥50% Hispanic youth aged 0–18 years were included. Using a weighted inverse-variance procedure, fixed-effects and random-effects models were run for an overall effect size on the basis of the Qtotal test statistic. Hedges’ g was calculated for outcomes of interest between baseline and postintervention separately for studies with multiple versus single conditions. Continuous and categorical moderators were also examined.
Results
A total of 1,103 articles were screened, of which 117 were included in the narrative synthesis and 105 in the meta-analysis (n=49,276 youth). The overall effects for RCT/quasi-experimental studies on BMI status (g= −0.15, SE=0.03, 95% CI= −0.20, −0.10), waist circumference (g= −0.15, SE=0.10, 95% CI= −0.35, −0.05), physical activity (g=0.12, SE=0.05, 95% CI=0.03, 0.22), fruit and vegetable intake (g=0.08, SE=0.02, 95% CI=0.03, 0.12), and sugar-sweetened beverage intake (g= −0.07, SE= 0.03, 95% CI= −0.13, −0.01) were small. Intervention effects varied by participant developmental stage, SES, study setting, and lifestyle behavior target.
Discussion
Beyond developing more impactful interventions to address obesity among Hispanic youth, findings highlight the need for targeted policies and more easily disseminable interventions that can spread small effects across a population for maximal public health impact.
Background
Promoting adolescent physical activity is crucial as this marks a time when physical activity rates decline.
Purpose
This study examined motivation for physical activity from a self-determination theory (SDT) perspective in a large sample of adolescents in the USA across three settings: in school, out of school, and on weekends.
Methods
Participants (N = 1,661) were adolescents from the National Cancer Institute’s Family Life, Activity, Sun, Health, and Eating study. Participants had a mean age of 14.47 (standard deviation = 1.61) and were 50.2% female. In this national sample balanced to match the U.S. population on several key demographics, 64.2% were non-Hispanic White. Analyses included three linear regression models in which estimated weekly minutes of moderate-to-vigorous physical activity (MVPA) in school, out of school, and on weekends were entered as dependent variables. Five forms of motivation (intrinsic, integrated, identified, introjected, and external) were entered simultaneously as independent variables. Age, body mass index, gender, and race/ethnicity were also included as covariates.
Results
All models were significant. For MVPA in school, external regulation, introjected regulation, identified regulation, and intrinsic motivation were positively associated with MVPA. For MVPA out of school, external regulation, introjected regulation, identified regulation, integrated regulation, and intrinsic motivation were positively associated with MVPA. For MVPA on weekends, integrated regulation, and intrinsic motivation were positively associated with MVPA.
Conclusions
The relationship between motivation and MVPA varies across settings. These findings have important implications for motivating adolescents to engage in physical activity and may inform future interventions aimed at increasing physical activity.
Innovative lifestyle interventions are needed to reduce type 2 diabetes risk in adolescents. This report describes the protocol of the Imagine HEALTH cluster randomized control trial, that tests an intervention based in Self-Determination Theory (SDT) and uses lifestyle education combined with the mind-body, complementary health modality of guided imagery (GI), to address obesity prevention and treatment in predominantly Latino adolescents. The primary aim is to determine the unique effects of each of the three major components of the 12-week lifestyle intervention (lifestyle education, stress reduction guided imagery, and lifestyle behavior guided imagery) compared to control on primary outcomes of physical activity (accelerometry), dietary intake (3-day recall), and stress biomarker levels (salivary cortisol). Secondary aims assess changes compared to controls in psychosocial outcomes (stress, well-being, depression), diabetes-related metabolic outcomes (adiposity, insulin resistance), maintenance of outcome changes for one year post-intervention, and SDT-based mediation of intervention effects. The development and rationale for each of the intervention components, study design, and outcome measurement processes are described. Adolescent participants recruited from four urban schools are cluster randomized by school into one of four arms of the 12-week (3-month) intervention, followed by 6 months of maintenance and 6 months of no contact. Outcome measures are assessed at the end of each period (3-, 9-, and 15-months). Results to date show successful recruitment of 97% of the target study population. Future results will demonstrate the effects of this integrative intervention on primary and secondary outcome measures in adolescents at risk for lifestyle-related metabolic disease.
Many adolescents have poor diet and physical activity behaviors, which can lead to the development of noncommunicable diseases in later life. Digital platforms offer inexpensive means of delivering health interventions, but little is known about their effectiveness. This systematic review was conducted to synthesize evidence on the effectiveness of digital interventions to improve diet quality and increase physical activity in adolescents, to effective intervention components and to assess the cost-effectiveness of these interventions. Following a systematic search, abstracts were assessed against inclusion criteria, and data extraction and quality assessment were performed for included studies. Data were analyzed to identify key features that are associated with significant improvement in behavior. A total of 27 studies met inclusion criteria. Most (n = 15) were Web site interventions. Other delivery methods were text messages, games, multicomponent interventions, emails, and social media. Significant behavior change was often seen when interventions included education, goal setting, self-monitoring, and parental involvement. None of the publications reported cost-effectiveness. Due to heterogeneity of studies, meta-analysis was not feasible.It is possible to effect significant health behavior change in adolescents through digital interventions that incorporate education, goal setting, self-monitoring, and parental involvement. Most of the evidence relates to Web sites and further research into alternate media is needed, and longer term outcomes should be evaluated. There is a paucity of data on the cost-effectiveness of digital health interventions, and future trials should report these data.
Context:
Existing evidence shows that text message interventions can produce short-term health behavior change. However, understanding is limited regarding intervention characteristics moderating this effect or the long-term effectiveness of text message interventions on behavior change after contact stops.
Evidence acquisition:
MEDLINE, PubMed Central, ERIC, PsycINFO, and Web of Science were searched for articles published between April 2008 and December 2014 that evaluated an intervention targeting preventive health behaviors, delivered primarily by text message.
Evidence synthesis:
Intervention development and design characteristics and research outcomes were evaluated for 51 studies. Thirty-five studies were included in a meta-analysis (conducted in 2015) examining overall effect size and moderators of effect size. The overall pooled effect of interventions was d=0.24 (95% CI=0.16, 0.32, p<0.001) using outcome data collected most proximal to intervention cessation. Seven studies collected data following a no-intervention maintenance period and showed a small but significant pooled maintenance effect (d=0.17, 95% CI=0.03, 0.31, p=0.017, k=7). Few variables significantly moderated intervention efficacy. Interventions that did not use a theoretic basis, used supplementary intervention components, and had a duration of 6-12 months were most effective. The specific behavior being targeted was not associated with differences in efficacy nor was tailoring, targeting, or personalization of text message content.
Conclusions:
Text message interventions are capable of producing positive change in preventive health behaviors. Preliminary evidence indicates that these effects can be maintained after the intervention stops. The moderator analysis findings are at odds with previous research, suggesting a need to examine moderators at the behavior-specific level.
Background:
Technological instruments may help control paediatric obesity.
Objective:
We tested whether a personalized programme based on the energy expenditure obtained from a wristband (WB) and the energy intake obtained from a smartphone application (APP) is superior to a standard approach at promoting weight loss.
Methods:
We performed a randomized controlled trial in obese children aged 10-17 years. The experimental (EXP) and control (CTR) groups were given a low-energy diet and a prescription for physical activity. The EXP group was equipped with a WB and an APP and given personalized feedback every 7 days. The main outcome was weight loss at 3 months.
Results:
The mean (standard deviation) z-score of body mass index at the enrollment was 2.20 (0.47) in the EXP (n = 16 out of 23) and 2.09 (0.34) in the CTR group (n = 14 out of 20) of children who completed the trial. The mean (95%CI) difference in weight loss at 3 months was 0.07 kg (95%CI: 2.81 to 2.96) for EXP vs. the CTR.
Conclusion:
A personalized lifestyle programme based on a WB and an APP was not superior to a standard lifestyle programme at promoting weight loss in obese children.
Objective:
Feasibility trials assess whether a behavior change program warrants a definite trial evaluation. This paper reports the feasibility of an intervention consisting of Self Determination Theory-informed text messages, pedometers, and goal prompts to increase adolescent physical activity.
Methods:
A 4-group randomized design with baseline and immediate post-study assessments was used. Groups (pedometer; pedometer + goal prompt; pedometer + goal prompt + theory-informed texts; no-treatment control) were systematically varied to assess the additive effect of intervention components on objectively measured physical activity (ie, ActiGraph). The primary outcome of the 12-week intervention was program feasibility. Changes in average daily step counts and minutes of moderate-to-vigorous physical activity also were examined. Post-intervention research with a subset of participants examined program reactions.
Results:
Participants (N = 160) were evenly split by sex, mostly 14-15 years old, and of diverse race/ethnicity. Feasibility criteria were met. The attrition rate was less than 2%. Modest increases in average daily step counts and moderate-to-vigorous physical activity were observed in all groups except the control group. Participants reported positive reactions to the intervention.
Conclusions:
An intervention consisting of pedometers, theory-informed texts, and goal prompts, is a feasible and acceptable method for promoting physical activity to adolescents.
The extent to which self-determined motivation mediates the association of fulfillment of pupils' psychological needs for autonomy, competence, and relatedness with self-reported enjoyment and effort in elementary school Physical Education (PE) was examined. Self-report data were provided by 213 Greek fifth and sixth graders on the aforementioned variables. Using Preacher and Hayes (2008) mediation analysis, it was found that all three needs directly and positively predicted pupils' enjoyment and effort. Indirect effects emerged for autonomy and relatedness in regard to effort but not enjoyment. The findings support to a large extent the validity of self-determination theory motivational dynamics in elementary school PE.
This paper presents a conceptual model of key factors that characterize a socio-culturally targeted approach to physical activity intervention design and delivery.
Diabetes is a costly disease affecting 387 million individuals globally and 28 million in the United States. Its precursor, prediabetes, affects 316 and 86 million individuals globally and in the United States, respectively. People living with elevated blood glucose levels are at high risk for all-cause mortality and numerous cardiometabolic ailments. Fortunately, diabetes can be prevented or delayed by maintaining a healthy lifestyle and a healthy body weight. In this review, we summarize the literature around lifestyle diabetes prevention programs and provide recommendations for introducing prevention strategies in clinical practice. Overall, evidence supports the efficacy and effectiveness of lifestyle diabetes prevention interventions across clinical and community settings, delivery formats (eg, individual-, group-, or technology-based), and implementers (eg, clinicians, community members). Evidence-based diabetes prevention strategies that can be implemented in clinical practice include brief behavior change counseling, group-based education, community referrals, and health information technologies. These strategies represent opportunities where practitioners, communities, and health care systems can work together to provide individuals with education, support and opportunities to maintain healthy, diabetes-free lifestyles.
Federal guidelines state that youth should participate in a variety of physical activity (PA) they find enjoyable. Little is known, however, about how variety and enjoyment are associated with PA participation among adolescents.
Data came from the 2010 National Youth Physical Activity and Nutrition Survey, a nationally representative survey of adolescents. Path analysis was used to examine the association of a variety of self-reported PA, defined as the number of activities and activity types (i.e., team sports/weightlifting, individual activities, and other competitive/recreational sports), on self-reported PA enjoyment and participation. The analysis also examined whether enjoyment mediates the association between a variety of PA and participation. Separate models were estimated for boys and girls.
Number of activities was associated with increased PA enjoyment and participation. For boys and girls, team sports/weightlifting was associated with increased participation, and individual activities were indirectly associated with increased participation through enjoyment. For boys, team sports/weightlifting was indirectly related with participation.
These findings suggest that participation in a variety of PA is associated with increased PA enjoyment and participation. Providing opportunities for adolescents to engage in a variety of activities might help them identify PA they enjoy and facilitate lifelong PA habits.
The aim of this systematic review of reviews is to identify mobile text-messaging interventions designed for health improvement and behavior change and to derive recommendations for practice. We have compiled and reviewed existing systematic research reviews and meta-analyses to organize and summarize the text-messaging intervention evidence base, identify best-practice recommendations based on findings from multiple reviews, and explore implications for future research. Our review found that the majority of published text-messaging interventions were effective when addressing diabetes self-management, weight loss, physical activity, smoking cessation, and medication adherence for antiretroviral therapy. However, we found limited evidence across the population of studies and reviews to inform recommended intervention characteristics. Although strong evidence supports the value of integrating text-messaging interventions into public health practice, additional research is needed to establish longer-term intervention effects, identify recommended intervention characteristics, and explore issues of cost-effectiveness.
Obesity prevention among youth of low SES is a public health priority given the higher prevalence of youth obesity in this population subgroup.
To evaluate the 24-month impact of a school-based obesity prevention program among adolescent girls living in low-income communities.
The study was a school-based group RCT, the Nutrition and Enjoyable Activity for Teen Girls (NEAT Girls) intervention.
The study involved 12 secondary schools located in low-income communities in New South Wales, Australia. Participants were 357 adolescent girls (aged 13.2±0.5 years).
The 12-month multicomponent intervention was guided by social cognitive theory and involved strategies to promote physical activity, reduce sedentary behaviors, and improve dietary outcomes.
The primary outcome was BMI, and secondary outcomes were BMI z-score; percentage body fat (bioelectrical impedance analysis); physical activity (accelerometers); dietary intake; and recreational screen-time (self-report). Data were collected in 2010-2012 and analyzed in 2012.
After 24 months, there were no intervention effects on BMI (adjusted mean difference -0.33, 95% CI= -0.97, 0.28, p=0.353) and BMI z-score (-0.12, 95% CI= -0.27, 0.04, p=0.178). However, there was a group-by-time interaction for percentage body fat (-1.96%, 95% CI= -3.02, -0.89, p=0.006). Intervention effects for physical activity, screen time, and dietary intake were not significant.
The NEAT Girls intervention did not result in effects on the primary outcome. Further study of youth who are "at risk" of obesity should focus on strategies to improve retention and adherence in prevention programs.
This study is registered at Australian New Zealand Clinical Trials ACTRN1261000033004.
Background:
Supporting lifestyle change is an effective way of preventing recurrent events in people with cardiovascular disease (CVD). However, there is a need to develop innovative strategies that increase access to programmes for individuals at high risk of CVD. This study aimed to develop a bank of text messages designed to provide advice, motivation, and support for decreasing cardiovascular risk.
Design:
Iterative development process with mixed methods
Methods:
An initial bank of 120 text messages was drafted based on behaviour change techniques, guidelines, and input from clinicians and public health experts. A questionnaire was then administered to participants (n = 53) for evaluation of message content, usefulness, and language. To test the process of delivery, a pilot study was conducted using a specifically designed computer programme that delivered messages to multiple mobile phones according to a pre-specified schedule. Data were collected regarding message timing, delivery, and usefulness.
Results:
In the qualitative questionnaire, 92% of participants found the messages easy to understand and 86% found the messages contained useful information. Positive feedback was also obtained from the pilot study. Based on these results, together with suggestions provided, several messages were reworded and an additional 44 were written. The need for semi-personalization was also identified and a random set of 103 individualized messages was created.
Conclusions:
A final bank of 137 mobile telephone text messages designed to support behaviour change and decrease cardiovascular risk have been developed through a multistep iterative process. This provides a scientific approach for future developers of health-related text messages.
Adolescents participating in weight loss programs experience difficulty adhering to behavior change recommendations. Communications technology provides a low cost means to increase the frequency of contact with adolescents which can improve their engagement and also lead to behavior change. Within a larger project on the development of tailored text messages for adolescents enrolled in an existing multidisciplinary weight management program, this study explored participants' perspectives about message content. A library of messages was developed focused on topics central to weight management. Four focus groups were conducted with a total of 24 participants from the weight management program to gage their reactions to the messages. Detailed notes from the focus groups were analyzed to assess the acceptability of individual messages and to identify overriding themes. Results indicate that participants were very enthusiastic about receiving text messages. They preferred messages that provided recipe ideas, included successful weight loss strategies used by peers, and requested feedback regarding their progress. They preferred positive, encouraging, and direct messages. They were unanimous that messages should include encouraging symbols (e.g., exclamation points and "smiley faces") as often as possible. They emphasized that any mention of unhealthy foods or behaviors would trigger them to eat those foods or engage in those behaviors. Text messaging acronyms (e.g., LOL) were considered too informal for messages from healthcare providers. This study suggests that including text messages in obesity interventions is acceptable to obese adolescents as a means of supporting their weight loss efforts, and it highlights the need for such messages to be carefully constructed.
Mobile phone text messaging is a potentially powerful tool for behavior change because it is widely available, inexpensive,
and instant. This systematic review provides an overview of behavior change interventions for disease management and prevention
delivered through text messaging. Evidence on behavior change and clinical outcomes was compiled from randomized or quasi-experimental
controlled trials of text message interventions published in peer-reviewed journals by June 2009. Only those interventions
using text message as the primary mode of communication were included. Study quality was assessed by using a standardized
measure. Seventeen articles representing 12 studies (5 disease prevention and 7 disease management) were included. Intervention
length ranged from 3 months to 12 months, none had long-term follow-up, and message frequency varied. Of 9 sufficiently powered
studies, 8 found evidence to support text messaging as a tool for behavior change. Effects exist across age, minority status,
and nationality. Nine countries are represented in this review, but it is problematic that only one is a developing country,
given potential benefits of such a widely accessible, relatively inexpensive tool for health behavior change. Methodological
issues and gaps in the literature are highlighted, and recommendations for future studies are provided.